CLINICAL ARTICLE Midtrimester abortion using vaginal misoprostol for women with three or more prior cesarean deliveries Muhammad Fawzy ⁎, El-Said Abdel-Hady Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt abstract article info Article history: Received 11 December 2009 Received in revised form 16 February 2010 Accepted 8 March 2010 Keywords: Cesarean delivery Misoprostol Second-trimester pregnancy termination Uterine scars Objective: To evaluate the safety and efficacy of vaginal misoprostol for second-trimester abortion in women with 3 or more prior cesarean deliveries. Methods: This study was conducted with 138 women who needed pregnancy termination between 13 and 26 gestational weeks, 31 with 3 or more previous cesarean deliveries and 107 with no uterine scars (the controls). Misoprostol was inserted in the vagina every 6 hours until regular contractions or products of conception appeared, a 200-μg tablet for the first 24 hours and 2 tablets thereafter. The outcomes assessed were successful vaginal abortion, hemorrhage requiring blood transfusion, incomplete abortion, and uterine rupture. Results: A vaginal abortion occurred in 28 women (90.3%) in the study group and 107 (100%) in the control group (P = 0.01). There were no significant differences in the prevalence of the other assessed outcomes. Conclusion: Vaginal misoprostol appears to be safe and acceptably effective for second- trimester pregnancy termination in women with 3 or more previous cesarean deliveries. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction The cesarean delivery rate has increased over the last 2 decades, and pregnancy termination has become a more common procedure during the same period. Consequently, a specific group has emerged, one of women with previous uterine scars who require a second-trimester termination of pregnancy. The use of misoprostol for termination of pregnancy was first described in 1994 [1]. Because of its low cost, high effectiveness, and stability at room temperature, this synthetic analogue of the naturally occurring prostaglandin E 1 has since been widely used both orally and vaginally for pregnancy termination [2]. Although a vaginal adminis- tration has been shown to offer longer activity and greater bioavail- ability than the oral route, and to be associated with a lower incidence of adverse effects [3], rupture of the uterus is a complication of medical abortion in the second trimester when misoprostol is used vaginally [4]. There have been reports on the effectiveness and possible complications of vaginal misoprostol in women with prior 1 or 2 cesarean deliveries [5,6], but there is little information about the safety of misoprostol for women with 3 or more prior cesarean deliveries. The aim of the present study was to evaluate the safety and efficacy of misoprostol used vaginally for second-trimester abortion in women with 3 or more cesarean deliveries. 2. Patients and methods This study was conducted from June 2006 through May 2009 at Mansoura University Hospital, Mansoura, Egypt with 138 women who needed pregnancy termination between 13 and 26 gestational weeks. Terminations were performed for missed abortion, fetal death, fetal anomaly, premature rupture of membranes, and maternal disease. Of these women, 31 had undergone 3 or more cesarean deliveries and 107 (the controls) had no uterine scars. The study was approved by the ethics committee of Mansoura University Hospital. Each woman was counseled by a senior obstetrician and signed written consent before the procedure. Misoprostol (Cytotec; Pfizer, New York, NY, USA) was inserted vaginally every 6 hours, a 200-μg tablet for the first 24 hours and 2 tablets thereafter, until regular uterine contractions were observed or the products of conception were expelled. A transabdominal ultrasound examination was done following expulsion of products of conception to verify that the abortion was complete. Women who did not abort within 48 hours of misoprostol use underwent surgical evacuation (if the gestation was less than 15 weeks); or received additional doses of misoprostol; or received a transcervical Foley catheter with extra-amniotic PgF 2α instillation 0.5 mg every 2 hours; or received an intravenous infusion of oxytocin. If abortion did not occur within 72 hours of the first misoprostol insertion, the treatment was considered to have failed completely and the option of hysterotomy was discussed with the patient. If fetal membranes and/or placental remnants were retained, they were surgically evacuated to complete the abortion. The time to abortion was defined as the interval between the placement of the first tablet of misoprostol and the expulsion of the International Journal of Gynecology and Obstetrics 110 (2010) 50–52 ⁎ Corresponding author. Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura, Egypt. Tel.: + 20 10 519 0610. E-mail address: mmfawzy@hotmail.com (M. Fawzy). 0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.02.008 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo